CLINICAL INVESTIGATIONS Inhaler Technique Education and Exacerbation Risk in Older Adults with Asthma or Chronic Obstructive Pulmonary Disease: A Meta-Analysis Tiago Maricoto, MD,* † Luís Monteiro, MD, †‡ Jorge M.R. Gama, PhD, § Jaime Correia-de-Sousa, MD, ¶k and Luís Taborda-Barata, MD** ††‡‡ OBJECTIVES: To evaluate the effect of inhaler education programs on clinical outcomes and exacerbation rates in older adults with asthma or chronic obstructive pulmonary dis- ease (COPD). DESIGN: Systematic review and meta-analysis. SETTING AND PARTICIPANTS: Older adults with asthma or COPD, either in primary or secondary health care and pharmacy setting. MEASUREMENTS: We searched the Medline, Embase, and Central databases according to the main eligibility criteria for inclusion: systematic reviews, meta-analysis, clinical trials and quasi-experimental studies; participants aged 65 and older; education on inhaler technique and reporting of disease con- trol and exacerbation rates. We used the Grading of Recom- mendations, Assessment, Development and Evaluations scale for quality assessment and used a random-effect model with Mantel–Haenszel adjustment to perform a meta-analysis. RESULTS: We included 8 studies (4 randomized, 4 quasi- experimental) with a total of 1,812 participants. The most fre- quent type of intervention was physical demonstration of inhaler technique, training with placebo devices. Five studies showed significant reduction in exacerbation rates (pooled risk ratio=0.71, 95% confidence interval=0.59–0.86; p < .001), although effect on disease control and quality of life showed high discrepancy in the reported results, and all randomized studies revealed uncertainty in their risk of bias assessment. CONCLUSION: All interventions seemed to improve inhaler performance and clinically relevant outcomes, but a placebo device could be the most effective. There is evidence that inter- ventions reduce exacerbation risk in older adults, although to an overall moderate degree. J Am Geriatr Soc 00:1–10, 2018. Key words: asthma; chronic obstructive pulmonary dis- ease; inhalers A sthma and chronic obstructive pulmonary disease (COPD) affect up to 10% of the population, and many individuals with these conditions have uncontrolled symp- toms. 1 They experience frequent exacerbations, some of which can be life threatening. Up to 53% of community-treated indi- viduals may experience exacerbations, and good adherence to therapy is associated with reductions in exacerbations in half of cases. 2–4 Inhaled therapy is the most widely used treatment, but up to 90% of individuals used incorrect technique in clini- cal studies, 5 partly because the extensive variety of inhalers and their technical specifications create significant barriers to understanding of proper use. 6 Although all available inhalers may be equally efficient when properly used, 7 there are vari- ous device- and person-related factors that may significantly influence performance. 8–11 Poor inhaler technique is associated with worse symptom control 12,13 and leads to greater health- care resource consumption and costs. 14 Some studies have showed that teaching inhaler tech- nique may lower the risk of exacerbations and death in these individuals, 2,3,15–17 but the effect of teaching decreases with time, indicating the importance of regular reassessment. 9,18,19 There are many tools for teaching inhaler technique, 20 and two systematic reviews have addressed this. One concluded From the *Aveiro-Aradas Family Health Unit Aveiro Healthcare Centre, Aveiro, Portugal; † Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal; ‡ Esgueira + Family Health Unit Aveiro Healthcare Centre, Aveiro, Portugal; § Centre of Mathematics and Applications, Faculty of Sciences, University of Beira Interior, Covilhã, Portugal; ¶ Life and Health Sciences Research Institute/3B’s—PT Government Associate Laboratory, University of Minho, Braga, Portugal; k Horizonte Family Health Unit, Unidade Local de Saúde, Matosinhos, Portugal; **CICS—Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal; †† NuESA—Environment and Health Study Group, Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal; and the ‡‡ Department of Allergy and Clinical Immunology, Cova da Beira University Hospital Centre, Covilhã, Portugal. Address correspondence to Tiago Maricoto, Faculty of Health Sciences, University of Beira Interior, USF Aveiro-Aradas, Praceta Rainha D. Leonor, Aveiro 3800; Portugal. E-mail: tiago.maricoto@gmail.com DOI: 10.1111/jgs.15602 JAGS 00:1–10, 2018 © 2018, Copyright the Author Journal compilation © 2018, The American Geriatrics Society 0002-8614/18/$15.00